A nurse is reviewing the diagnostic test results of a female client who is about to undergo knee arthroplasty. Which of the following data collection findings should the nurse identify as the priority?
Creatinine 0.9 mg/dL
WBC count 20,000/mm3
Potassium 3.8 mEq/L
Hematocrit 40%
The Correct Answer is B
a. Creatinine 0.9 mg/dL: This creatinine level is within the normal range and is not an immediate priority for knee arthroplasty.
b. WBC count 20,000/mm3: An elevated white blood cell count suggests the presence of
infection or inflammation. In the context of knee arthroplasty, infection is a significant concern and requires immediate attention to prevent complications.
c. Potassium 3.8 mEq/L: This potassium level is within the normal range and is not an immediate priority for knee arthroplasty.
d. Hematocrit 40%: This hematocrit level is within the normal range and is not an immediate priority for knee arthroplasty. The elevated WBC count takes precedence as it suggests a
potential infectious process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin
secretions in a client with a tracheostomy.
b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.
c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.
d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing
humidified oxygen is a more appropriate approach.
Correct Answer is B
Explanation
a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.
b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.
c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.
d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS
complexes is maintained.
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